Disclaimer: I am extremely biased on the topic being addressed here.
There are some days I think of myself as a “survivor.” Being an ACLR (anterior cruciate ligament reconstruction) “survivor” of sorts, I feel the need to speak out about it, advocate and share my rather biased opinions. There’s always been some “buzz” around the timeframe for return to sport following ACLR. Pundits like Timothy Hewett are hypothesizing we should wait 2-3 years before returning an athlete to play after surgery.(1) While much of our current literature does indeed show improved outcomes 1-2 years out postoperatively, I take this recommendation seriously. I want to share my “why” with you because I feel like it’s an extremely important conversation to have for the sake of those who have had this surgery.
I tore my ACL when I was 16 years old. A classic, non-contact injury in soccer. I was out of shape when it happened and put into a game situation unprepared. There are many reasons why I likely tore my ACL when I did, including the ones just mentioned (ie. my fitness), as well as my tendency towards quadriceps dominance, valgus alignment with high level movements, and the fact that I was a developing female who played a cutting and pivoting contact sport. But really, my risk was not any more or less than the person next to me, as it seems that we aren't that good at predicting injuries in the first place. At the time, I was in the midst of recruiting season for college. I wanted to play division I soccer and that was probably the only real goal I ever made when I was that age. Naturally, this injury took the wind out of my sails in what was literally an instant.
After surgery, I went through post-op rehab in what turned out to be 5 months (according to my mother it was 4 months, but for the sake of being generous, we’ll say it was 5).
"Hello, my name is Ellie, I’m 32 years old and I survived an ACL repair as a young, female soccer player without a secondary tear after returning to full competitive play at 5 months."
That summer, I went to numerous college scout tournaments, playing with teams I didn't know in an attempt to be seen by a coach and picked up for a team. I’ve been told that I was “lucky.” Lucky to have returned so soon, but mostly lucky to have not torn a second time. I agree, there may have been some luck involved, you cannot deny that. The claim that I was lucky is hard to hear and does make me uncomfortable, mostly because I believe that luck had very little do with it at all. And by telling me I was lucky, it neglects to understand, what it was about me, that allowed me to be successful after the surgery. I'm here to say we need to start looking the other way, so to speak. The literature shows us that roughly 25-30% of athletes will re-tear their ACL and I find I’m struck with wonder when I think, what happens to the other 70-75% of athletes who don’t tear again and what makes them different?
Luck is defined as “success or failure apparently brought by chance rather than through one's own actions” (Google). Here’s where taking it personally comes into play...I worked my ass off during rehab. I was highly motivated to return to play as fast as possible and it showed. I was committed to performing the exercises, strength training, being a part of my soccer team and was named team captain 1 month after surgery. At the 5 month mark, I was put through a battery of tests including hop tests, vertical jump tests, strength tests, fitness tests, agility tests. This was in 2002 mind you. Passed them all at 90% or better side to side but will fully admit to not feeling the same, so to speak. Is this a unique outcome? Sure. Did it arrive by luck? Well that's something we may never know, but as my biased self would say...absolutely not.
As I've already indicated, research shows us that approximately 30% of athletes will go on to secondary ACL tears (2,5). This is particularly true for young athletes that return to competitive play too soon after surgery. I understand that 30% is still a damn good portion of the athletes we see, but 30% is NOT the majority. In fact, there is a group of 70% of people out there who are apparently considered “lucky” too. I’m no mathematician, but I’m pretty sure the odds were in my favor at the start.
So why are we in such a tizzy about the timeframe for return to sport? The main reason is because we believe we need to do better, and I do not disagree. No one wants their patient to sustain a secondary ACL injury and I guarantee the patient doesn't want to either. But the problem that I see happen, is that we allow that fear to facilitate a neglect to recognize the individual and characteristic differences in all of us. We reduce a person’s opportunity to succeed or fail based on statistics and time. Can we predict which ones will go on to secondary injury? The likely answer is no. So why do we continue to persist in our journey to make this injury worse than it already is by holding them back for so long? I would love to see us learn to take a step back to look at the WHOLE person. Using the numbers in a way that empowers a person’s recovery and doesn’t hold them back. Flipping the statistics towards the positive.
For me, return to play shouldn’t be about 6 months, 9 months, 12 months, or 2 years. It shouldn’t be about the 30% of those that re-tear. It should be about your patient, the person in front of you, THEIR goals, THEIR passions, THEIR hope for their future and in my opinion, about their ability to SUCCEED and not their likelihood to fail. We don’t empower our patients or boost them with confidence when we say to them…”30% of people who have this surgery will re-tear their ACL.” We scare them. I believe fear isn’t the answer towards improving outcomes, I believe it's empowerment. My knee will never be the same, but it doesn't mean the rest of my life has to suffer because of it.
Dr. Ellie Somers, Physiotherapist
Nagelli CV, Hewett TE. Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate Ligament Reconstruction? Biological and Functional Considerations. Sports medicine (Auckland, NZ). 2016 Jul 11. PubMed PMID: 27402457. Epub 2016/07/13. Eng.
Webster KE, Feller JA, Leigh WB, Richmond AK. Younger Patients Are at Increased Risk for Graft Rupture and Contralateral Injury After Anterior Cruciate Ligament Reconstruction. The American journal of sports medicine. 2014 March 1, 2014;42(3):641-7.
Webster KE, Feller JA, Whitehead TS, Myer GD, Merory PB. Return to Sport in the Younger Patient with Anterior Cruciate Ligament reconstruction. Orthop J Sports Med. 2017 Apr 25;5(4):
Graziano J, Chiaia T, de Mille P, Nawabi DH, Green DW, Cordasco FA. Return to Sport for Skeletally Immature Athletes AFter ACL Reconstruction. Preventing a Second Injury Using a Quality of Movement Assessment and Quantitative Measures to Address Modifiable Risk Factors. Orthop J Sports Med. 2017 Apr 20;5(4)
- Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jul;44(7):1861-76. doi: 10.1177/0363546515621554. Epub 2016 Jan 15.